Queensland University of Technology and
Royal Brisbane Hospital
Cancer nursing is a relatively young specialty within nursing. The specialty initially emerged in response to scientific, professional and social developments in the 1950s, which saw the beginning of radical changes to the way cancer was managed, and the way professionals and the public viewed the disease1. Miaskowski1 identifies four factors that influenced the development of cancer nursing, alongside the development of cancer medicine, as a specialty:
These changes created a range of new roles and responsibilities for nurses caring for people with cancer, and over the past few decades these roles have continued to evolve in response to the changing social and health care environment. Cancer nurses today are integral members of the cancer care team, and cancer nursing has become established as a major specialty within nursing. Cancer nurses in Australia and overseas have published standards to define and guide their practice2,3, and specialist postgraduate courses and research programs within cancer nursing have emerged in many universities and health care facilities in Australia.
However, like other health professions practising in the today’s health care system, cancer nurses today are facing many challenges associated with cost containment, rapid developments in science and technology, and the changing relationships between consumers and health professionals. In addition, the nursing profession is currently experiencing unique problems associated with recruitment and retention of specialist nurses, with oncology nursing having recently been listed by the Department of Workplace Relations and Small Business as an area of skills shortage in New South Wales, the ACT, Queensland and the Northern Territory4.
The series of articles presented in this edition of Cancer Forum aims to explore some of the contributions made by nurses to cancer control efforts in Australia. Specifically, the articles in this edition provide an overview of contemporary issues in the provision of education and support for people with cancer and their families. The developing evidence base underpinning nursing practice is also highlighted in a paper which uses the example of intervention strategies for treatment induced mucositis. At the broader policy level, the development of guidelines for handling cytotoxic drugs and related waste is discussed to illustrate how nurses have effectively collaborated with a range of key stakeholders to enhance safe practice for health care workers and patients. Issues faced by cancer nurses and people with cancer in rural Australia, and new roles and directions for cancer nurses are also considered in the final papers in this series. To provide some context for the articles included in this edition, a number of key issues and challenges facing contemporary cancer nursing will be discussed in this first paper.
In 1996, the COSA Nurses Group published its second edition of Outcome Standards for Australian Cancer Nursing Practice2. The document, along with other similar documents published in the USA3, highlights the diverse and complex nature of cancer nursing practice. In particular, the Outcome Standards identify that:
More specifically, a recent qualitative study exploring the key dimensions of practice for nurses working in chemotherapy settings in Australia identified that chemotherapy nursing practice revolves around interrelated processes associated with information giving and education, emotional support, advocacy, and a range of direct caregiving interventions. These interventions require specialised knowledge and skills in managing technology, assessing responses to disease and treatments, preventing and responding to symptoms and treatment side effects, and meeting the patient’s personal care needs5.
A growing number of reports from randomised and case control studies are documenting the benefits of nursing intervention in terms of improved patient outcomes and consumer satisfaction with care. For example, a recent study of 1300 patients reported in theJournal of the American Medical Association identified that patient outcomes for nurse practitioner and physician delivery of primary care do not differ6. In the context of specialist cancer care, researchers from the UK have similarly reported evidence which suggests that advanced nurse practitioners are effective in managing patients’ responses during the course of radiotherapy7, although these studies are yet to be published in the peer reviewed literature.
In the Australian context, the recently published NHMRC NBCC Psychosocial Guidelines reports Level II evidence that specialist breast nurse intervention can reduce women’s psychological morbidity, increase their understanding of breast cancer, improve their recall of information and perceptions of support, enhance early recognition of their support needs, and provide continuity of care throughout the treatment process8. Furthermore, the NBCC Specialist Breast Care Nurse project has identified that, compared with a retrospective control and the National Consumer Survey, women seeing a specialist breast care nurse received more information about aspects of breast cancer and treatment, were more likely to be told about clinical trials and overall to participate in these trials, and were more likely to report having had or considered having reconstructive surgery9.
While few studies to date have examined the economic benefits of specialist cancer nursing services, it is reasonable to assume that effective education, support and coordination of care, the core elements of good nursing practice, can contribute to a reduction in health expenditure by decreasing lengths of stay and preventing the unnecessary use of health services.
There are a number of recent developments within cancer nursing that are of particular note in considering nursing’s role in cancer care. Firstly, the redefinition of professional boundaries, and the changing scope of practice for nurses and of other health professionals have major implications for cancer care. Practices which where once viewed as the sole responsibility of a medical practitioner (for example, talking with patients about disease and prognosis), are now more often recognised as being concerns for the entire team. In some cases, this changing scope of practice for nursing is being institutionalised in new roles, such as the nurse practitioner.
The necessary legislative and policy change has already occurred in some states to facilitate these developments. Indeed, for a range of political and economic reasons, issues associated with the scope and models of nursing practice are clearly on the agenda for most state governments at the present time. Even the Federal Government, which has typically viewed the nursing workforce as being a concern for the states, has recently convened a national forum to consider nursing workforce issues. As a result of the forum held in September 1999, the Australian Health Workforce Advisory Committee was established in late 2000, along similar lines to that of the Australian Medical Workforce Advisory Committee (AHMAC). This attention currently being given to nursing workforce issues provides some unique opportunities for nurses to establish key collaborative relationships with other health professionals to improve patient outcomes, and provide increased consumer choice and satisfaction10.
Secondly, the evidence base underpinning nursing intervention is developing. Nurse researchers are making important contributions to knowledge of cancer control through both qualitative and quantitative studies. The focus of nursing research is broad, and has tended to address issues relating to human experiences associated with cancer, factors that may influence this experience, and nursing interventions to prevent and manage problems associated with cancer and its treatment.
Nursing research is also making unique contributions to investigation of issues and problems which have received only limited attention to date (such as the management of difficult symptoms including breathlessness and fatigue, and family support), and nurse researchers have developed and evaluated innovative integrated models for managing cancer related problems7. At least two meta analyses of nursing research studies have been published which have concluded that various teaching and symptom management interventions implemented by nurses do produce more effective patient outcomes11,12.
In Australia, cancer nursing research is in its infancy, and the extent to which research findings are yet to impact on the practice of nurses in this country is not clear. Nonetheless, developments in nursing research over the past decade are promising for future cancer control efforts in this country.
Nurses today are also educated in a radically different system to that of the past. The transition of nursing education to the higher education sector is now well established, with registration as a nurse in Australia requiring completion of a three year undergraduate degree. Specialist postgraduate certificate and diploma courses in cancer nursing have also been established in the higher education sector in most states of Australia. These Graduate Certificate and Graduate Diploma level programs typically articulate with Masters level degrees, which provide nurses with the opportunity to undertake further study in advanced practice issues or research. These programs thus provide a pathway for nurses wishing to specialise in cancer nursing, and develop advanced knowledge and skills in this field. An increasing number of these courses are available through flexible modes of delivery, effectively overcoming many of the social and geographical barriers to undertaking further studies.
However, while educational opportunities are becoming more widely available, the increasing cost of higher education to the individual is becoming prohibitive for some nurses. Unlike those who pursue postgraduate studies in other disciplines, there is not necessarily any private benefit for nurses in terms of investment in education, even though the public benefit is likely to be significant13. Moreover, the benefits of these radical changes to nursing education continue to be the subject of debate in some arenas, as concerns are raised about the higher education sector’s ability to respond to the rapidly changing clinical environment and prepare graduates with advanced clinical skills. Models of postgraduate education in nursing will therefore continue to evolve, and much closer linkages between industry and the higher education sector are rapidly becoming the norm.
Recent years have also seen an increasing awareness of the important role that nursing plays in the provision of cancer services for underserved populations. For example, Registered Nurses are now being trained as Pap smear providers. These nurses receive extensive training and are accredited based on national standards to ensure the quality of the practice14. These services have proven to be especially valuable in rural and remote areas. With the growing awareness of the unique needs of these special populations, the role for cancer nurses is likely to become even more important in the future.
The developments which have occurred within nursing over the past few decades provide much reason to be optimistic about the contribution that has already made by nursing services to cancer control in Australia. However, issues relating to increasing nursing workloads, and the location of nursing within the health system, have recently become major areas of concern for the profession.
There is good evidence that nursing workloads have increased substantially in recent years. The most recent Nursing Labour Force report from the Australian Institute of Health and Welfare indicates that while the number of full time equivalent (FTE) nurses employed in public acute and psychiatric hospitals declined by 2.8% between 1995-96 and 1998-99, the number of patient separations has increased by 7.4%. In private acute hospitals, the number of FTE nurses employed during this time increased by 11%, however, the number of patient separations increased by 16%4.
Cancer nurses practising in outpatient and day treatment facilities can attest to the implications that these changes have had for the throughput of patients in these settings, and for the type of education and support required by patients and their families. It is not surprising then that a recent qualitative study of nurses working in chemotherapy settings in Australia identified that many cancer nurses had concerns about their ability to provide quality cancer care in the present health care environment. Resource issues were identified by participating nurses as being a major cause of frustration and distress, as they recounted numerous examples where lack of resources had prevented them from providing the care they believed patients required5.
Related to these workload issues is the growing concern amongst some members of the nursing profession that one of the major factors contributing to current workforce problems in nursing is that a large proportion of the profession feels undervalued, is excluded from decision making, and is therefore unwilling or unable to work in the present environment.
The report of proceedings from the National Nursing Workforce Forum convened by the Commonwealth Government in September 1999 concluded that many nurses perceived there is a gap between what nurses can do, and the public and government understanding or acceptance of that potential. Participants at the forum argued that this is evidenced in the relatively minor role nurses have in decision making about health policy and service provision, and the relatively low level of funding for nursing research15. These circumstances have led various nursing leaders to ask whether it is that “educated, articulate and questioning nurses are no longer willing to work in a system that does little to validate them, to recognise their new status or acknowledge their central place in health care”16, and to question “why governments still cling to the outdated view of nurses as a pair of hands, rather than as a resource for shaping the health care to be delivered”17.
Indeed, nurses have historically had difficulty identifying and placing a value on their contribution to care of patients18, and clearly articulating their vision for cancer nursing services of the future. While medicine can demonstrate its contribution to cancer treatment with statistical results, the outcomes of nursing interventions are not always as easily measured in terms of its effect on outcome nor publicly displayed in graphical format19. The contribution that good nursing care makes to patient outcomes often remains unnoticed and is less than explicit20. As a result, individual judgements about nursing’s contribution to health care tend to be made arbitrarily20, making specialist nursing services, and the benefit that they bring for patients, more vulnerable in times of cost reduction.
For quality cancer care to be delivered, a number of issues relating to nursing services need to be addressed. The Commonwealth Government’s recent announcement of the establishment of the Australian Health Workforce Advisory Committee (AHWAC) provides an important opportunity to achieve a nationally coordinated approach to addressing the multiple factors adversely impacting on the nursing workforce. AHWAC met for the first time late in 2000, and established that its initial workforce planning focus will be on the nursing subspecialities of critical care, emergency nursing, aged care, mental health and midwifery. It will be important to monitor the progress of this committee, and ensure cancer nursing issues are also considered in the appropriate forums. This will require nurses to further develop health policy knowledge and skills, if they are to influence the outcomes of government and local institutional policy in a positive way.
It is also important that cancer nurses strengthen their collaborative relationships with colleagues in other disciplines. This is especially critical at the present time where the practice of all health professionals is changing, so that the focus remains on the needs of the person with cancer, rather than any one professional group. There is increasing recognition that the barriers between different health professional groups whether these be between nurses and other health professionals, or between registered nurses and other levels of nurses, can impede patient care16. The benefits of team approaches in cancer care are obvious if the complex multifaceted problems experienced by patients and their families are to be addressed more effectively.
Strategies for advancing research in cancer nursing are also required, since the development of evidence based nursing practice that is grounded in a sensitive understanding of human responses to cancer is an essential component of quality cancer care. More research training opportunities, and strategies for addressing the limited funding presently available for nursing research will be important for the future of cancer nursing in this country. This does not mean funding poor quality research, but rather a strategic consideration of the most effective way to utilise scarce research funds and training resources in order to achieve good outcomes across the range of areas that are necessary for a comprehensive approach to cancer control.
In conclusion, it is also important to acknowledge that more meaningful collaboration with the consumers of nursing services must be a central component of future cancer care. Nurses often pride themselves on their close relationships and their ability to “know” patients, emphasising the unique opportunities provided by the 24 hour intensive nature of nurse-patient interactions.
Nurses are, however, sometimes criticised for being inflexible in their views about what they believe is “right” for their patients, and reluctant to consider changes to the way nursing care is delivered. In doing so, it is possible that nurses may at times unknowingly overlook the experiences and wishes of their patients. Nurses will need to continue to critically reflect on their practice, and be willing to ask themselves whose interests are being served by the various actions of our profession. Cancer nurses active involvement in activities that improve communication with consumers and that fosters more collaborative relationships is essential for ensuring nurses continue to improve their ability to meet the needs of the person with cancer.
5. P Yates, M Hargraves, G Prest, J Cairns, K Harris, D Baker and A Thomson, “Factors impacting on contemporary chemotherapy nursing practice.” The Australian Journal of Cancer Nursing, 3 (2000), 2-11
6. M O Mundinger, R L Kane, E R Lenz, A M Totten, W-Y Tsai, P D Cleary, W T Friedewald, A L Siu and M L Shelanski. “Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial.” Journal of the American Medical Association, 283 (2000), 59-68.
8. NHMRC National Breast Cancer Centre Psychosocial Working Group. Psychosocial clinical practice guidelines: Providing information, support and counselling for women with breast cancer. Commonwealth of Australia, Canberra, 2000.
18. R McCorkle, M Grant, M Frank-Stromborg and S B Baird. “Cancer nursing as a speciality.” In R McCorkle, M Grant, M Frank-Stromborg and S B Baird (eds) Cancer nursing: a comprehensive textbook (chapt. 1). W B Saunders, Philadelphia, 1996.
19. C R Krcmar. “Cancer nursing as a speciality.” In: R McCorkle, M Grant, M Frank-Stromborg and S B Baird (Eds.) Cancer nursing practice: a textbook for the specialist nurse (chapt. 1). Churchill Livingstone, Philadelphia, 2000.